The Current State of the Epidemic:
Why We Need to Step Up Our Efforts

3. Too many people with HIV are not receiving, or are resistant to, treatment; and too many are dying

After dropping significantly in the mid-1990s, deaths from HIV/AIDS continue to occur. Some have expressed a fear that deaths may actually have increased recently, pointing, among other things, to the large number of well-known HIV/AIDS activists who have died in recent years (including one member of the steering committee that assisted in the development of this document). Complex issues related to managing treatments have also emerged.

Most people dying now from AIDS were either not treated at all, not treated soon enough orfaced challenges in finding the right or most appropriate medication. Some cannot tolerate the medications or have strains of the virus that are resistant to treatment.10 Others find it difficult to manage the complex demands of treatment regimens (e.g., the number of pills, when they have to be taken, etc.). In some cases, the complexity makes treatment inaccessible. A study in British Columbia has found that high AIDS death rates persist because of a lack of, or only marginal access to, antiretroviral therapy among certain populations. The study showed that one of every three people who die of AIDS in British Columbia has never been treated with antiretroviral drugs. Aboriginal persons, women, poor people, and people residing in the Downtown Eastside were overrepresented in this group. The researchers concluded that interventions aiming at improving access to antiretrovirals among HIV-infected Aboriginal persons, women, lower-income persons and people who use injection drugs are an urgent priority. They suggested that strategies to improve access and adherence could include better access to illegal-drug treatment programs, directly observed therapy programs, access to medical services without appointment, and on-site pharmacies at medical clinics.11 Despite major efforts by Canadian prison systems, prisoners with HIV/AIDS also continue to have problems accessing treatment comparable to that available outside prisons. A significant number of prisoners with HIV discontinue antiretroviral treatment while in prison.12 In addition, CATIE reports an increase in calls about salvage therapy for failing regimens and drug resistance.13

The overall prevalence of primary drug resistance was 8.6% in a sample of newly diagnosed individuals whohad never received antiretroviral treatment; in this same sample, the prevalence of multi-drug resistance (resistance to more than one class of antiretroviral drugs) was 1.3%. In Canada, primary drug resistance has been observed in both females and males; across different age groups, ethnicities, and exposure categories; in HIV-1 subtypes A, B, and C infections; and among recent and established HIV infections. This prevalence of primary drug resistance is similar to the rates observed in other countries where highly active antiretroviral treatment is widely used. 14

These trends also highlight the need for earlier diagnosis, the advent of new treatments and vaccines, less complex treatment regimens, and access to hospice and palliative care.

Footnotes

10
Harrigan PR, Hogg RS, Dong WWY, Yip B, Wynhoven B, Woodward J, Brumme CH, Brumme ZL, Mo T, Alexander CS, Montaner JSG. Predictors of HIV Drug Resistance Mutations in a Large Drug-Naïve Cohort Initiating Triple Antiretroviral therapy. BC Centre for Excellence in HIV/AIDS,Department of Medicine, University of British Columbia.

11
Wood E et al. Prevalence and correlates of untreated human immunodeficiency virus type 1 infection among persons who have died in the era of modern antiretroviral therapy. Journal of Infectious Diseases 2003; 188: 1164-1170.

12
Jürgens R. Canada: Does incarceration result in HIV treatment interruptions? Canadian HIV/AIDS Policy & Law Review 2004; Vol. 9, No 2: 49-50, with reference to T Kerr, A Marshall, J Walsh, A Palepu, MW Tyndall, RS Hogg, J Montaner, E Wood. Determinants of highly active antiretroviral discontinuation among injection drug users. Canadian Journal of Infectious Diseases 2004; 15 (Suppl A): 86A (abstract 458P).

13
Electronic communication from CATIE. June 2004.

14
Public Health Agency of Canada. HIV-1 Strain and Primary Drug Resistance in Canada: Surveillance Report to March 31, 2004. Surveillance and Risk Assessment Division, Centre for Infectious Disease Prevention and Control, Public Health Agency of Canada, 2005.

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